Documentation Guidelines

Guidelines for Documentation of Attention-Deficit/Hyperactivity Disorder

Students who desire accommodations from the Office of Student Disability Services on the basis of a diagnosed attention deficit/hyperactivity disorder (ADHD) are required to submit documentation to verify need and eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Protection under these civil rights statutes is based on documentation of a disability that substantially limits one or more major life activities, such as learning.

Since Christian Brothers University's goal is to provide reasonable and appropriate support services for students with disabilities, students are required to provide current and comprehensive documentation of their disability justifying a need for accommodation.

The following guidelines are provided to assure that documentation is appropriate to verify eligibility and is supportive of requests for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a diagnosed attention-deficit/hyperactivity disorder.

I. Qualifications of the Evaluator

The evaluator should have expertise in diagnosing attention deficit/hyperactivity disorder in adults and diagnosing other psychiatric disorders that might be comorbid or confused with ADHD. A qualified professional such as a neurologist, psychiatrist, licensed clinical or educational psychologist, licensed psychological examiner, or a combination of such professionals should make the diagnosis of ADHD.

II. Currency of Documentation

The assessment of ADHD should be current, preferably within three years of the student's request for disability services. Because the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disability on his/her academic performance, it is in the student's best interest to provide recent and appropriate documentation. If the documentation is outdated or inadequate in scope or content, it may be necessary to update the evaluation report or to request clarification or further information. Further, if co-existing learning disabilities or other disabling conditions are indicated, further assessment and/or documentation may be required.

III. Identification of DSM-IV-TR Criteria

Christian Brothers University subscribes to the definition of attention-deficit/hyperactivity disorder and the diagnostic criteria for it expounded in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). A diagnostic report should include a review and discussion of the DSM-IV-TR criteria for ADHD both currently and retrospectively and specify which symptoms are present.

The following DSM-IV-TR general criteria must be met in order for a diagnosis of ADHD to be made:

The person must display "a persistent pattern of inattention and/or hyperactivity-impulsivity for at least 6 months to a degree that is more frequent and severe than is typically observed in individuals at a comparable level of development."

"Some hyperactive-impulsive, or inattentive symptoms that cause impairment must have been present before age 7 years."

"Some impairment from the symptoms is present in two or more settings" (e.g., at school, work, and at home).

"There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning."

"The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another diagnosis (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)."

IV. Documentation Must Be Comprehensive

An individualized education program (IEP) or a 504 plan is insufficient documentation in and of itself, but can be included as part of a more comprehensive evaluative report.

The following information should be included in the assessment documentation:

Clear statement of the DSM-IV-TR diagnosis.

Date of diagnosis.

Summary of procedures and instruments used to make the diagnosis, to include diagnostic interview, aptitude testing, achievement testing, information processing and behavior rating scale.

A summary of evaluation results, including standardized scores.

Past and present symptoms that meet the DSM-IV-TR criteria for diagnosis.

Medical history relating to current use of medication and the impact of the medication on the student's ability to meet the demands of the academic program.

Statement of current impact and limitations on student's academic performance.

An interpretative summary based on a comprehensive evaluative process, to include demonstration of the evaluator's having ruled out alternative explanations for inattentiveness, impulsivity, and/or hyperactivity as a result of psychological or medical disorders or non-cognitive factors.

Recommendations for academic accommodations to compensate for the disability. Each accommodation recommended by the evaluator must include a rationale.

The name, title, and professional credentials of the evaluator. Information about license or certification as well as the area of specialization, employment, and state or province in which the individual practices should be clearly stated in the documentation.

All reports should be on letterhead, typed, dated, signed, and otherwise legible.

Further assessment and/or documentation by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. If LD, psychiatric, or physical disabilities are involved, please refer to the documentation guidelines for those specific disabilities.

Determinations of reasonable and appropriate accommodations are made by Christian Brothers University Disability Accommodation Committee and are based on the documentation information, evaluation of the documentation by an outside professional, the student's request for accommodations, and the tasks required for the student's courses as defined by individual faculty members. Accommodations are always individually determined.

Guidelines for Documentation of a Specific Learning Disability

Students who desire accommodations from the Office of Student Disability Services on the basis of a diagnosed learning disability (LD) are required to submit documentation to verify need and eligibility under Section 504 of the Rehabilitation Act of 1973 and Title III of the Americans with Disabilities Act of 1990. Protection under these civil rights statutes is based on documentation of a disability that substantially limits one or more major life activities, including learning.

Since Christian Brothers University's goal is to provide reasonable and appropriate support services for students with learning disabilities, students are required to provide current and comprehensive documentation of their disability justifying a need for accommodation.

The following guidelines are provided to assure that documentation is appropriate to verify eligibility and is supportive of requests for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a specific learning disability.

Qualifications of the Evaluator.
Professionals conducting assessments, rendering diagnoses of learning disabilities, and making recommendations for appropriate accommodations must be qualified to do so. Comprehensive training and direct experience with an adolescent and adult LD population is essential. Competence in working with culturally and linguistically diverse populations is also essential. Note: the name, title and professional credentials of the evaluator, including information about license or certification (e.g., licensed psychologist) as well as the area of specialization, employment and state in which the individual practices, should be clearly stated in the documentation.

Currency of Documentation.
The provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disability on his/her academic performance. Therefore, it is in the student's best interest to provide recent and appropriate documentation relevant to the student's learning environment. In most cases, this means testing that has been conducted within the past three years. If the documentation is outdated or inadequate in scope or content, it may be necessary to update the evaluation report or to request clarification or further information.

Substantiation of the Learning Disability.
A single test, an individualized education program (IEP) or a 504 plan are not considered sufficient for the purpose of diagnosis. Instead, the student's documentation should consist of a comprehensive assessment battery that includes: a diagnostic interview; assessment of aptitude; measures of academic achievement and information processing with test scores; a specific diagnosis; and a clinical summary that contains recommendations for specific accommodations.

Diagnostic Interview. An evaluation report should include the summary of a comprehensive diagnostic interview. Relevant information regarding the student's academic history and learning processes in elementary, secondary and post secondary education should be investigated. Areas that the diagnostician should address, using professional judgment as to which are relevant, include:

A description of the presenting problem(s); relevant developmental, medical, psychosocial and employment histories;

Family history (including primary language of the home, if other than English, and the student's current level of English fluency); and

A discussion of dual diagnosis where indicated.

Assessment.The neuropsychological or psycho educational evaluation for the diagnosis of a specific learning disability must provide clear and specific evidence that a learning disability does or does not exist. Evidence of a substantial limitation to learning or other major life activity must be provided. The evaluation should address the following areas, using tests such as those listed at the end of this section:

Aptitude: A complete intellectual assessment with all subtests and standard scores reported.

Academic Achievement: A comprehensive academic achievement battery is essential with all subtests and standard scores reported for those subtests administered. The battery should include current levels of academic functioning in relevant areas such as reading (decoding and comprehension), mathematics, and oral and/or written language.

Other assessment measures, such as non-standard measures and informal assessment procedures or observations, may be helpful in determining performance across a variety of domains. Other formal assessment measures may be integrated with the above instruments to help determine a learning disability and differentiate it from coexisting neurological and/or psychiatric disorders. In addition to standardized tests, it is also very useful to include informal observations of the student during the test administration.

Specific Diagnosis. Christian Brothers University subscribes to the definition and diagnostic criteria for specific learning disabilities outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). Nonspecific diagnoses, such as individual "learning styles," "learning differences," "academic problems," and "test difficulty or anxiety," in and of themselves do not constitute a learning disability. The evaluator should make a specific DSM-IV-TR diagnosis if indicated by the testing data.

Test Scores. Standard scores and/or percentiles should be provided for all normed measures. Grade equivalents are not useful unless standard scores and/or percentiles are also included. The particular profile of the student's strengths and weaknesses must be shown to relate to functional limitations that may necessitate accommodations.

Clinical Summary. A diagnostic summary based on a comprehensive evaluation process is a necessary component of the report. The clinical summary should include:

Indication of how patterns in the student's cognitive ability, achievement and information processing reflect the presence of a learning disability.

Indication of the substantial limitation to learning presented by the learning disability and the degree to which it affects the individual in the learning context for which accommodations are being requested.

Indication of why specific accommodations are needed and how the effects of the specific disability are mediated by the accommodations.

The summary must also include any record of prior accommodations or auxiliary aids, including any information about specific conditions under which the accommodations were used (e.g., standardized testing, final exams).

Recommendations for Accommodations.
The diagnostic report should include specific recommendations for accommodations, including an explanation as to why each accommodation is recommended. The evaluator should support recommendations with specific test results or clinical observations.

Determinations of reasonable and appropriate accommodations are made by Christian Brothers University's Disability Accommodation Committee and are based on the documentation information, evaluation of the documentation by an outside professional, the student's request for accommodations, and the tasks required for the student's courses as defined by individual faculty members. Accommodations are always individually determined.

Guidelines for Documentation of Psychiatric or Psychological Disability

Students who desire accommodations from the Office of Student Disability Services on the basis on a psychiatric or psychological disability are required to submit documentation to verify need and eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 (ADA). Protection under these civil rights statutes is based on documentation of a disability that substantially limits one or more major life activities. A diagnosis of a disorder/condition/syndrome in and of itself does not automatically qualify an individual for accommodations under the ADA.

A specific diagnosis by a licensed mental health professional including a licensed clinical social worker (LCSW), licensed professional counselor (LPC), psychologist, psychiatrist or neurologist is required. The diagnostician should be an impartial individual who is not a family member of the student.

Since Christian Brothers University's goal is to provide reasonable and appropriate support services for students with disabilities, students are required to provide current and comprehensive documentation of their disability justifying a need for accommodation.

The following guidelines are provided to assure that documentation is appropriate to verify eligibility and is supportive of requests for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a diagnosed psychiatric or psychological disorder. Recommended documentation should include:

A clear statement of disability, including the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) diagnosis.

A summary of current symptoms that satisfy the DSM-IV-TR criteria and the approximate date of onset.

A summary of historical information, diagnostic interview, and assessment procedures/ evaluation instruments used to make the diagnosis. A summary of evaluation results, including standardized or percentile scores, should also be included.

Medical information relating to the student's needs, to include current treatments and the impact of medication on the student's ability to meet the demands of the post secondary environment.

Statement of impact and limitations of the disorder on the student's academic performance.

Recommendations for reasonable accommodations and support services that are appropriate for the post secondary level. Each recommended accommodation must include a rationale and should be supported by the diagnosis.

Current documentation, preferably within the last year. Due to the nature of psychological and psychiatric disorders, updated reports may be requested.

The name, title, and professional credentials of the evaluator. Information about license or certification as well as the area of specialization, employment, and state or province in which the individual practices should be clearly stated in the documentation.

All reports should be on letterhead, typed, dated, signed, and otherwise legible.

Further assessment and/or documentation by an appropriate professional may be required if co-existing learning disabilities or other disabling conditions are indicated. If LD, ADHD, or physical disabilities are involved, please refer to the documentation guidelines for those specific disabilities.

Determinations of reasonable and appropriate accommodations are made by Christian Brothers University's Disability Accommodation Committee and are based on the documentation information, evaluation of the documentation by an outside professional, the student's request for accommodations, and the tasks required for the student's courses as defined by individual faculty members. Accommodations are always individually determined.

Guidelines for Documentation of a Physical Disability

Students who desire accommodations from the Office of Student Disability Services on the basis of a diagnosed physical disability are required to submit documentation to verify eligibility under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 (ADA). Protection under these civil rights statutes is based on documentation of a disability that substantially limits one or more major life activities. A diagnosis of a disorder/condition/syndrome in and of itself does not automatically qualify an individual for accommodations under the ADA.

Since CBU's goal is to provide reasonable and appropriate support services for students with disabilities, students are required to provide current and comprehensive documentation of their disability justifying a need for accommodation.

The following guidelines are provided to assure that documentation is appropriate to verify eligibility and is supportive of a need for reasonable accommodations, academic adjustments, and/or auxiliary aids on the basis of a disability.

As appropriate to the disability, documentation should include:

A diagnostic statement identifying the disability, date of the current diagnostic evaluation, and the date of the original diagnosis.

The diagnostic taxonomies used by the Department of Education, the Department of Rehabilitative Services or other State agencies and/or the current editions of either the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or the International Classification of Diseases Manual (ICD-10) are recommended.

Documentation should be current within three years, but exceptions may be necessary, dependent upon individual circumstances and the nature of the disability. Since the provision of all reasonable accommodations and services is based upon assessment of the current impact of the student's disabilities on his/her academic performance, it is in the student's best interest to provide recent and appropriate documentation.

A description of the diagnostic criteria and/or diagnostic test used.

This description should include the specific results of diagnostic procedures and diagnostic tests utilized. When available, both summary and specific test scores should be reported as standard scores and the norming population identified. When standard scores are not available, the mean, standard deviation, and the standard error of measurement are requested as appropriate to the construction of the test.

Diagnostic methods used should be congruent with the disability and current professional practices within the field. Informal or non-standardized evaluations should be described in enough detail that a professional colleague could understand their role and significance in the diagnostic process.

A description of the functional impact of the disability.

The current functional impact on physical, perceptual, and cognitive abilities should be described. Currency will be evaluated based on the typical progression of the disability, its interaction with development across the life span, the presence or absence of significant events (since the date of the evaluation) that would impact functioning, and the applicability of the information to the current context of the request for accommodations.

A description of treatments, medications, assistive devices and/or assistive services in current use and their estimated effectiveness in ameliorating the impact of the disability should be included. Significant side affects that may impact physical, perceptual, or cognitive performance should also be noted.

A description of the expected progression or stability of the impact of the disability over time.

This description should provide an estimate of the change in the functional limitations of the disability over time and/or recommendations concerning the predictable needs for reevaluation.

Recommendations for accommodations, adaptive devices, assistive services, and support services, with accompanying rationale.

Based on the context of the diagnostic evaluation, recommendations for specific accommodations, adaptive devices, and/or assistive services that would ameliorate the functional impact of the disability and provide fuller access should be described. As appropriate, recommendations for collateral medical, psychological, and/or educational support services or training that would be beneficial may also be included.

The credentials of the diagnosing professional(s).

Information indicating the certification, licensure, and/or the professional training of individuals conducting the evaluation should be provided.

Determinations of reasonable and appropriate accommodations are made by CBU's Disability Support Committee and are based on the documentation information, evaluation of the documentation by an outside professional, the student's request for accommodations, and the tasks required for the student's courses as defined by individual faculty members. Accommodations are always individually determined.